Clostridum Difficile Diarrhoea

A04.7

*Notifiable medical condition.

DESCRIPTION

Diarrhoea caused by altered bowel flora due to antibiotic exposure.
Clostridium difficile infection may result in severe disease and/or the development of pseudomembranous colitis.
Diagnosis is confirmed in the laboratory on a stool sample.  Patients with unexplained and new-onset diarrhoea of more than 3 unformed stools in 24 hours should be tested.  Repeat testing (within 7 days) is not recommended.

GENERAL MEASURES

  • The most important aspect of management is discontinuing antibiotics.
  • Rehydration may be necessary. This should be done with oral rehydration solution (ORS) unless the patient is vomiting or profoundly dehydrated.
  • Patients with known or suspected Clostridium difficile infection should be placed on contact precaution according institutional infection control and prevention measures.
  • Contact precautions should be maintained for at least 48 hours after diarrhoea has resolved.
  • Healthcare workers and all close contacts should perform regular handwashing with soap and water. Alcohol-based hand sanitizer does not kill spores.

MEDICINE TREATMENT

Loperamide is contraindicated as it may result in toxic megacolon.

Mild to moderate infection

Laboratory results confirm toxigenic Clostridium difficile infection, diarrhoea does not settle on antibiotic withdrawal:

  • Metronidazole, oral, 400 mg 8 hourly for 10 days.

Severe infection

Laboratory results confirm toxigenic Clostridium difficile infection, WCC >15 micromol/L or serum creatinine >132 micromol/L, or other risk predictors of severity (immunodeficiency, intensive care admission, serious comorbidity, age >65 years of age).

  • Vancomycin, oral, 125 mg 6 hourly (give parenteral formulation orally) for 10 days.

Fulminant infection

If ileus or toxic megacolon or hypotension/shock:

  • Vancomycin, oral, 125 mg 6 hourly (give parenteral formulation orally) for 10 days.

AND

  • Metronidazole, IV, 500 mg 8 hourly for 10 days.

Switch to oral metronidazole, if possible, to complete 10 day course.

Recurrence

If metronidazole was used during the first episode:

  • Vancomycin, oral, 125 mg 6 hourly (give parenteral formulation orally) for 10 days.

If vancomycin was used during the first episode, consider oral vancomycin as tapered and pulsed regimen:

  • Vancomycin, oral, 125 mg 6 hourly (give parenteral formulation orally) for 10 days, then 12 hourly for 7 days, then once per day for 7 days, and then every 2nd or 3rd day for 2 to 8 weeks.

LoEI [24]

REFERRAL

  • Surgical consult should be obtained in all patients with complicated Clostridium difficile infection (e.g. bowel perforation, hypotension requiring vasopressor therapy, clinical signs of sepsis).
  • Failure to improve on medical therapy after 5 days.